Archived: Dr Khin Thanda Also known as Avenham Lane Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Khin Thanda, also known as Avenham Lane Practice, on 7 December 2016. The practice was rated as inadequate for providing safe, effective, caring, responsive and well-led services and was placed into special measures for a period of six months. We also issued two warning notices in respect of safe care and treatment, and good governance. The full comprehensive report on the inspection on 7 December 2017 can be found by selecting the ‘reports’ link for Dr Khin Thanda on our website at www.cqc.org.uk.

This inspection was undertaken following the period of special measures and was an announced comprehensive inspection on 25 September 2017. At this most recent inspection we saw that the practice had taken steps to address some of the concerns identified at our previous inspection, however, some significant concerns remained and we also identified new concerns related to the clinical care of patients and the safe storage of refrigerated vaccines.

Overall the practice is still rated as inadequate.

Our key findings were as follows:

• We saw evidence that knowledge of and reference to national guidelines and guidance for patients’ clinical care and treatment by the principal GP was lacking. Medicines were on several occasions, prescribed inappropriately.
• There was evidence that patient treatment records had insufficient details to give assurance that an adequate clinical assessment of the patient had been made and there was a lack of recording of the patient medical history and clinical signs. We saw that referrals to other services lacked detail and that there was no system in place to follow up patients who did not book appointments with services after referral.
• There was limited evidence generally of quality improvement. There was an improved system for managing significant events, however actions taken as a result of events were not reviewed. A new audit programme had been introduced although it was in its early stages and documentation of audit required improvement.
• There was little documentation of clinical discussion and, although we saw that patient safety alerts had been addressed, there was no documentation of this and the principal GP was unaware of recent alerts.
• Systems to safeguard patients from abuse had improved since our last inspection although one practice policy to safeguard children was out of date. This was updated following our inspection.
• Records of temperatures made for refrigerated vaccines recorded temperatures over recommended levels for up to five days and the surgery had not responded appropriately to ensure patient safety. The use of loose prescription forms in the practice was not monitored.
• The practice had improved the cleanliness and hygiene of the premises since our last inspection and had introduced measures to ensure that the appropriate levels of infection prevention and control (IPC) were maintained although we saw a lack of risk assessment to assure patient and staff safety.
• The practice had failed to address the low results identified by our last inspection for the Quality and Outcomes Framework (QOF) which measured the review of patients with long-term health conditions. Results for this continued to fall (based on unvalidated figures). Low results for patient national cancer screening programmes had not been addressed and the identification of patients who were also carers was still poor.
• The practice had improved the process for working with other community and health and social care staff although we saw no evidence of care planning for vulnerable patients.
• The practice had failed to engage with patients to seek feedback on service development and delivery. As at our last inspection, there was no patient participation group and little attempt to seek patient feedback on areas for improvement. The practice still did not have a website and the practice social media page had very little information for patients. The practice had failed to address the high numbers of patients attending the local A&E department and patient concerns regarding access that were evidenced in the latest national GP patient survey.
• The practice complaints process had been improved since our last inspection and both written and verbal complaints were recorded. Patient comment cards that we received praised staff for being caring and helpful and for treating them professionally.
• We did not find that the leadership of the practice was sufficient to ensure high quality care for patients or good governance of the practice.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition the provider should:

• Enable sufficient records to be kept for clinical discussion in meetings to allow learning to be shared.
• Improve the system for documenting quality improvement work in the practice to ensure that learning outcomes can be clearly identified and acted upon.
• Continue to improve the identification of patients who are also carers.

This service was placed in special measures in December 2016. Insufficient improvements have been made and further concerns have been identified. There remains a rating of inadequate for providing safe, effective and well led services. Therefore we are taking action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration with the Care Quality Commission.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at the practice of Dr Khin Thanda on 7 December 2016. Overall the practice is rated as Inadequate.

Our key findings across all the areas we inspected were as follows

• There was a system in place for reporting and recording significant events.
• Risks to patients were assessed but steps to manage these risks were not always in place for example, in the care of patients with significant health problems.
• There was no gas safety certificate available for the building.
• The oxygen cylinder for use in an emergency was empty. The provider made arrangments immediately to have this replaced.
• Safeguarding processes within the practice were not embedded.
• There had been no recent audit on infection prevention and control; we found cleaning standards to be below those expected.
• There was limited evidence of clinical audit, learning from audit and of results being used to drive improvement.
• Latest available data showed that attendance of patients at accident and emergency units was high. The evidence provided by the practice on the day of inspection, and following the inspection did not demonstrate that the practice was working effectively to address this.
• Results from the Quality and Outcomes Framework (QOF) were below Clinical Commissioning Group (CCG) and national averages. There was no improvement plan in place to address this.
• Not all required recruitment checks were in place for all staff.
• Information about services and how to complain was not readily available. We found no formal complaints had been received for more than four years; verbal complaints were not recorded.
• The practice had good facilities and was equipped to treat patients and meet their needs.
• Staff assessed patients’ needs and delivered care in line with evidence based guidance.
• Clinical staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment. Administrative staff required training in areas such as infection control, and one staff member had not received training in safeguarding.
• There was a lack of leadership within the practice; there was no succession planning in place.
• There was no practice website available for patients to access information.
• We found evidence that access arrangements for patients between 6pm and 6.30pm were unsatisfactory. Calls to a mobile phone during this period had not been answered.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

The provider must put systems and processes in place to ensure care and treatment is provided in a safe way to service users, including:

• Assessing the risks to the health and safety of service users of receiving care or treatment;and

• Doing all that is reasonably practicable to mitigate such risks. This includes but is not limited to:

• Using and reviewing care plans and working effectively with community based clinicians to improve patient care;

• Learning from incidents involving patient care.

• Ensuring all emergency medicines including oxygen are available for use.

• Ensuring all cleaning systems and processes within the practice are correctly managed and maintained and that cleaning meets required standards.

• Ensuring that all staff receive training in infection control sufficient to support them in their role.

The provider must establish systems and processes which operate effectively that enable the registered person to:

• Assess, monitor and improve the quality of services through recognised quality improvement activity. This includes but is not limited to:

• Improving audit and using results to drive improvements in patient care.

• Implementing effective improvement activity to reduce the numbers of patients presenting at accident and emergency units.

• Use of effective improvement activity to increase patient satisfaction and sharing results with patients

• Ensuring the complaints process is accessible to all patients and keeping accurate records of all complaints.

• Reviewing safeguarding processes within the practice to ensure all staff understand their role and the administrative procedures that support the safeguarding responsibilities of the practice.

• Ensuring all safety governance checks are in place

• Ensure that all required recruitment checks are carried out and records of these are held.

• Ensure all staff training is delivered and records of this are up to date.

The areas where the provider should make improvements are:

• Develop a practice website to facilitate patients access to information.

• Invite the input of the locum GP on significant events, to improve learning outcomes.

• Schedule clinical meetings when the locum GP is able attend.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice